Registration Forms

Dear Patient,

Thank you for contacting our office, and we look forward to meeting with you.

In order to save you time when you come in for your appointment, our registration forms are available below. Please complete them at home and then bring with you. There are two versions of each form and you’re welcome to use whichever version you prefer.

If you have Microsoft Word

We suggest that you use the Word version of the forms. Simply open each form in Word, and you can use your “Tab” key to move from field to field, typing in the information required. If you’re unsure of what to enter, use the “F1” key on your keyboard to open a pop-up box with instructions for that field. When the form is complete, print two copies………one for your records and one to bring with you to your appointment. You can save the completed form to your hard drive by using the “Save As” command in the File menu in Word. Click File, then “Save As”, and save the form to the sub-directory of your choice on your hard drive.

Form 1 Medical History

Form 2 Contact & Insurance Information

If you don’t have Microsoft Word

We include the PDF version of each form for those who don’t own Word. These documents can be opened with the Adobe Acrobat Reader. If you don’t have the Acrobat Reader, Adobe offers a FREE version for download, and you can get a copy by clicking here. Once you have the Free Reader, you can open the PDF documents and print them, then fill them out by hand (we’re sorry, but Adobe doesn’t include form filling with their free Reader anymore).

Form 1 Medical History

Form 2 Contact & Insurance Information

If you have any questions or concerns about the forms, please don’t hesitate to call our office at 407-352-2444 and we’ll be happy to assist you!

Other New Patient considerations

Please be aware that only certain insurance plans are accepted. It is your responsibility to verify that we are on your plan. Please call the phone number on the back of your card and confirm that we are a physician on their panel. We will still be happy to see you if we are not on your plan, but we cannot file your insurance and you will be expected to pay in full at the time of your visit. We offer a 20% discount for those out of network that pay at the time of their treatment.

In the state of Florida, if you are on a HMO plan, you are allowed five (5) visits a year without a referral from your primary care doctor. It is your responsibility to get a referral for the sixth (6th) visit to see Dr. Meisenheimer.

Due to the new HIPPA laws passed by the Federal Government you will be required to bring a photo I.D. Also, if the patient is under the age of 18 we cannot see them without a parent or legal guardian. Please do not send your child with family members such as Grandma or Aunt until we have written authorization from you to see your child in the care of another adult.

Ladies, please do not wear any makeup, i.e., foundation or cover up. You may want to bring makeup with you to apply after the examination.

If you should have any other questions, please do not hesitate to call our office and speak to one of our staff at 407-352-2444.

For directions click here: Directions

We look forward to seeing you!

Dr. John “Lucky” Meisenheimer, MD
South Orlando Dermatology

© John “Lucky” Meisenheimer, M.D.  2019